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psych.anxiety-disorders.core.v1

Anxiety Disorders (GAD / panic / social anxiety / specific phobia / agoraphobia) — chronic stepwise + acute panic (APA Panic 2009; NICE NG185 2024; CANMAT 2014 Katzman PMID 25081580)

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Start encounter →Print handoutPRODUCTION

Anxiety-disorders dossier — APA Panic 2009 + NICE NG185 2024 + CANMAT 2014 Katzman PMID 25081580 + VA/DoD Anxiety + PTSD 2022 Covers GAD (F41.1, lifetime ~6%), panic disorder (F41.0, ~5%), social anxiety (F40.10-11, ~12%), specific phobia (F40.2x, ~12%), agoraphobia (F40.00, ~1-2%); mixed anxiety F41.3 common (~50% have ≥2 anxiety disorders) Step 1 SSRI/SNRI: escitalopram 5-10 → 20 (most effective + adolescent GAD FDA); sertraline 25 (start LOW for panic) → 200 (pregnancy + lactation preferred); paroxetine 10 → 50 (AVOID pregnancy); fluoxetine 10-20 → 60 (long half-life); fluvoxamine 50 → 300 (OCD-spectrum); citalopram 10-20 → 40 (20 if elderly per FDA QTc); venlafaxine XR 37.5-75 → 225 (FDA GAD + social anxiety + panic); duloxetine 30 → 60-120 (FDA GAD; comorbid pain) Step 2 switch: SSRI ↔ SNRI cross-class OR within-class SSRI switch; anxiety responds slower than depression — full 8 wk often needed before declaring failure Step 3 augmentation: buspirone 7.5 BID → 60 (GAD ONLY; no falls / cognitive impact — geriatric preferred); mirtazapine 7.5 → 45 QHS (sleep + appetite + low-fall-risk); pregabalin 75 BID → 600 (GAD Level 1 CANMAT 2014; off-label US); gabapentin 100-300 TID off-label; propranolol 10-40 mg PRN for performance / situational social anxiety ONLY Acute panic ED axis: cardiac r/o FIRST (workup.chest_pain registered umbrella) → single-dose lorazepam 0.5-1 mg PO/SL → outpatient bridge ≤2 wk → NO long-term benzo prescription at discharge CRITICAL anti-pattern: NEVER long-term benzodiazepine monotherapy for anxiety (NICE NG185 2024; CANMAT 2014; VA/DoD 2022; Beers 2023); short-term bridge < 4-6 wk acceptable; gradual taper 10-25% Q2-4 wk hyperbolic-style beyond that Severity triggers (10): acute_panic_attack_in_ed, severe_anxiety_with_suicidal_ideation (routes to psych.suicidality.ed.core.v1), anxiety_with_treatment_resistance_after_2_ssris, benzodiazepine_dependence_emergent_withdrawal (routes to psych.alcohol_withdrawal.core.v1 management principles), pregnancy_with_anxiety_medication_decision, pediatric_anxiety_with_ssri_initiation (CAMS Walkup NEJM 2008 + AACAP 2007), geriatric_anxiety_with_fall_risk (Beers 2023 AVOID benzo), serotonin_syndrome_features_with_polypharmacy (life-threatening; workup.hyperthermic_toxidromes umbrella), comorbid_substance_use_dual_diagnosis (routes to psych.alcohol_withdrawal / psych.opioid_use_disorder), gad7_above_15_severe_functional_impairment Two setting playbooks: outpatient primary care (GAD-7 + PHQ-9 + C-SSRS cadence, SSRI/SNRI ladder, CBT-with-exposure, Horowitz hyperbolic taper, MDQ pre-SSRI for suggestive features, lethal-means counseling if SI history, benzo taper plan) + acute ED (cardiac r/o, single-dose lorazepam, bridge ≤2 wk, no long-term benzo at discharge) Action plan green/yellow/red includes panic-attack coping (4-7-8 / box breathing, 5-4-3-2-1 grounding) + exposure-hierarchy homework + benzo self-escalation warning + cardiac-red-flag chest-pain rule + Stanley-Brown safety plan + 988 lifeline Sibling differentiation: psych.depression.core.v1 (~50% comorbid MDD; SNRI dual-indication), psych.bipolar-disorder.core.v1 (MDQ before SSRI; switch caution), psych.suicidality.ed.core.v1 (active SI cross-route; compose not replace), psych.alcohol_withdrawal.core.v1 (benzo withdrawal management principles shared; AUD ~20-25% comorbid), psych.opioid_use_disorder.core.v1 (CRITICAL: NEVER benzo + opioid per FDA 2016 black-box) Front-end note: src/components/panels/ob-peds-psych/gad-panel.tsx is the existing GAD-7 screening UI surface; this dossier is the back-end pathway pack. No panel→dossier wire today — flagged for future wire-up batch. Workup IDs all resolve to registered umbrellas in clinical-tools-registry — workup.suicide_risk + workup.severe_agitation + workup.hyperthermic_toxidromes + workup.chest_pain + workup.insomnia. Calculator IDs all resolve to registered tools — calc.gad7 + calc.phq9 + calc.audit_c + calc.ckd_epi_2021. calc.cssrs + calc.mdq + calc.spin / calc.lsas (Social Phobia Inventory / Liebowitz Social Anxiety Scale) flagged for future clinical-tools-registry batch — referenced via narrative + workup.suicide_risk for now. Phenotype matrix (anxiety_type × severity_gad7 × comorbidity × treatment_history × age × pregnancy / lactation × suicidality_cssrs) is encoded indirectly via severity_triggers + setting_playbooks + sibling_differentiation. First-class TS field for phenotype matrix is schema-blocked — see docs/framework-audit/shard-5-obped-id-state.md Schema-blocked queue. Bayesian linkage (GAD-7 ≥10 LR+ ~5-7 per Spitzer 2006; PHQ-9 + GAD-7 simultaneous detects ~50% MDD comorbid; MDQ LR+ ~7 in psych outpatients; C-SSRS gradient anchors disposition; TSH suppression LR+ ~20 for hyperthyroid mimic; T_treat = GAD-7 ≥10 + functional impairment OR ≥15; T_test = GAD-7 <5 + no functional impact; T_switch = 4-8 wk adequate dose; T_augment = ≥2 SSRI/SNRI failed; T_taper_benzo = 10-25% Q2-4 wk hyperbolic-style; T_taper_SSRI = Horowitz hyperbolic; cross-dossier routing to psych.depression + psych.bipolar + psych.suicidality.ed + psych.alcohol_withdrawal + psych.opioid_use_disorder + workup.hyperthermic_toxidromes + workup.chest_pain documented in co-located research bundle). ROS/DDx LR seed data audited by npm run audit:ros-ddx-coverage (cross-cutting; not touched by this shard). PRODUCTION blockers / open gaps: (1) RxCUIs not yet validated via scripts/research/rxnav-validate.ts; (2) manifest reuses psych.depression.core.v1.ts pointer per peds.febrile-infant / psych.bipolar / psych.alcohol_withdrawal / psych.suicidality precedent — dedicated manifest out-of-shard-scope; (3) calc.cssrs + calc.mdq + calc.spin / calc.lsas not in clinical-tools-registry — referenced via workup.suicide_risk + narrative; (4) CAMS Walkup NEJM 2008, Horowitz Lancet Psych 2019, Hirschfeld MDQ 2000, Beers 2023, Boyer NEJM 2005 PMIDs NEEDS_SOURCE_REVIEW — referenced by label only; not added to evidence.pmids per verification rule; (5) CANMAT 2024 anxiety update PMID NEEDS_SOURCE_REVIEW — CANMAT 2014 PMID 25081580 retained as canonical anchor; (6) targeted test file pending (relies on dossier-contract.test.ts); (7) panel→dossier wire from gad-panel.tsx not authored — flagged for future wire-up batch.

Entry points (9)

  • symptom
    Excessive worry / anxious apprehension difficult to control ≥6 months (DSM-5-TR 2022 GAD criterion A; F41.1)
    excessive_worry_anxious_apprehension
  • symptom
    Recurrent unexpected panic attacks + persistent concern about additional attacks (DSM-5-TR 2022 panic disorder criterion A; F41.0)
    recurrent_unexpected_panic_attacks
  • symptom
    Marked fear / anxiety about social situations with possible scrutiny ≥6 months (DSM-5-TR 2022 social anxiety disorder; F40.10)
    fear_of_social_scrutiny
  • symptom
    Marked fear / avoidance of specific object or situation (DSM-5-TR 2022 specific phobia; F40.2x)
    specific_phobia_avoidance
  • symptom
    Fear / avoidance in ≥2 of 5 agoraphobic situations (DSM-5-TR 2022; F40.00)
    agoraphobia_fear_of_escape_difficulty
  • symptom
    Restlessness / fatigue / concentration / irritability / muscle tension / sleep disturbance (DSM-5-TR 2022 GAD criterion C)
    somatic_anxiety_symptoms
  • lab_abnormality
    GAD-7 ≥10 on routine screening (Spitzer Arch Intern Med 2006 PMID 16717171; USPSTF 2023 anxiety screening B-recommendation)
    positive_gad7_screen
  • problem_list
    Existing anxiety disorder with inadequate response, relapse, or breakthrough symptoms (CANMAT 2014 Katzman PMID 25081580; APA Panic 2009)
    anxiety_disorder_existing_uncontrolled
  • history
    Acute panic attack presenting to ED — cardiac / PE / thyrotoxic / hypoglycemia / pheo r/o required (APA Panic 2009; AHA / ACEP)
    acute_panic_attack_ed_presentation

Required inputs (16)

  • agerequired
    demographic • used at CONTEXT
    Drug selection + dose; pediatric (FDA black-box adolescent suicidality 2004; CAMS Walkup NEJM 2008; AACAP 2007); geriatric (Beers 2023 AVOID benzo, lower SSRI start dose; CANMAT 2014 Katzman)
  • pregnancy_statusrequired
    demographic • used at CONTEXT
    SSRI choice (sertraline preferred for lactation; paroxetine AVOIDED FDA Category D); MFM coordination if severe (APA reproductive psychiatry; NICE NG185 2024)
  • gad7_scorerequired
    symptom • used at RISK_STRATIFICATION
    GAD-7 stratifies severity → SSRI/SNRI + therapy intensity (Spitzer 2006 PMID 16717171; minimal 0-4, mild 5-9, moderate 10-14, severe ≥15)
  • phq9_scorerequired
    symptom • used at CONTEXT
    PHQ-9 — ~50% comorbid MDD in anxiety patients (CANMAT 2014 Katzman); Q9 flags suicidality; informs SNRI vs SSRI choice (Kroenke 2001 PMID 11556941)
  • suicidality_assessmentrequired
    symptom • used at RED_FLAGS
    C-SSRS — anxiety + comorbid MDD substantially elevates SI risk; FDA 2004 black-box adolescent surveillance; mandatory at intake + first 4 wk of any new antidepressant (Posner 2011 PMID 22193671; VA/DoD 2022)
  • prior_anxiety_treatment_responserequired
    history • used at CONTEXT
    Prior SSRI / SNRI / CBT response determines next step in ladder (STAR*D-style framework; CANMAT 2014 Katzman)
  • manic_or_hypomanic_historyrequired
    history • used at CONTEXT
    Rule out bipolar — MDQ screen — antidepressant alone may precipitate manic switch (Hirschfeld 2000 NEEDS_SOURCE_REVIEW; APA 2023; CANMAT 2014)
  • substance_userequired
    history • used at CONTEXT
    Comorbid SUD ~20-25% (AUD especially); benzo question complicated; FDA 2016 benzo + opioid black-box; AVOID benzo in active SUD (VA/DoD 2022; CANMAT 2014)
  • benzodiazepine_exposure_historyrequired
    history • used at CONTEXT
    Identify ≥4-6 wk regular benzo exposure → gradual taper mandatory; abrupt cessation → seizure / DT-like delirium risk (NICE NG185 2024; CANMAT 2014)
  • medical_comorbidityrequired
    history • used at CONTEXT
    CV / renal / hepatic / seizure / sleep apnea affect drug choice + workup; thyroid / cardiac mimics of anxiety (CANMAT 2014; APA Panic 2009)
  • current_medsrequired
    medication • used at CONTEXT
    MAOI washout 14 d; serotonergic load (SSRI + SNRI + tramadol + linezolid risk); CYP interactions; QTc; benzo + opioid overdose synergy (FDA 2016); SSRI + NSAID bleeding
  • tshrequired
    lab • used at INITIAL_WORKUP
    Hyperthyroidism mimics anxiety / panic — baseline before initiating SSRI; LR+ ≈ 20 if TSH suppressed + free T4 high (APA Panic 2009; CANMAT 2014)
  • cbc
    lab • used at INITIAL_WORKUP
    Baseline before therapy; rule out anemia / occult illness
  • bmp
    lab • used at INITIAL_WORKUP
    Baseline electrolytes + glucose (hypoglycemia mimics panic); SIADH risk on SSRI in elderly (Beers 2023; APA 2023)
  • lft
    lab • used at INITIAL_WORKUP
    Hepatic-cleared agents; duloxetine LFT monitoring (CANMAT 2014)
  • ecg
    imaging • used at INITIAL_WORKUP
    QTc baseline before citalopram >20 mg (FDA 2012); ED panic differential vs ACS in middle-aged + older adult (APA Panic 2009; AHA / ACEP)

12-phase flow (12)

  1. 1FRAME
    Confirm DSM-5-TR 2022 anxiety disorder criteria — GAD ≥6 mo excessive worry with ≥3 of 6 somatic; panic disorder recurrent unexpected attacks + concern; social anxiety ≥6 mo + scrutiny fear; specific phobia / agoraphobia per criteria; functional impairment; not better explained by SUD / medical / bipolar / OCD / PTSD (DSM-5-TR 2022; APA Panic 2009)
    advance: Anxiety disorder subtype criteria met and bipolarity / OCD / PTSD ruled out
  2. 2ENTRY
    Trigger from GAD-7 ≥10 (USPSTF 2023 anxiety screening B-recommendation; Spitzer 2006), symptomatic presentation, panic-attack ED presentation, postpartum risk, or relapse
    inputs: age, gad7_score
    advance: Entry criteria documented
  3. 3CONTEXT
    Prior anxiety treatment + response, manic history (MDQ), substance use, benzo exposure history, psychosocial stressors, medical comorbidities, current meds, pregnancy status
    inputs: prior_anxiety_treatment_response, manic_or_hypomanic_history, substance_use, benzodiazepine_exposure_history, medical_comorbidity, current_meds, pregnancy_status, phq9_score
    advance: Personalisation data captured
  4. 4RED_FLAGS
    Active suicidality with intent / plan / means (C-SSRS; especially in comorbid MDD); severe benzo-withdrawal-with-DT-like-delirium; severe agitation; serotonin syndrome features on polypharmacy; pregnancy on valproate (if bipolar-spectrum considered); first-presentation acute panic without cardiac r/o in middle-aged + older adult; severe functional collapse
    inputs: suicidality_assessment
    actions: workup.suicide_risk
    advance: Safety plan in place OR ED disposition initiated OR cardiac r/o complete (APA Panic 2009; VA/DoD 2022)
  5. 5INITIAL_WORKUP
    TSH, CBC, BMP, LFTs (baseline per APA Panic 2009; CANMAT 2014); ECG if QTc-prolonging drug planned (FDA 2012) OR first-presentation acute panic in middle-aged / older adult; pregnancy test; cardiac biomarkers + chest pain workup if ED panic presentation
    inputs: tsh
    advance: Baseline labs returned + cardiac r/o complete if ED
  6. 6BRANCHING_WORKUP
    24-h urine metanephrines / plasma free metanephrines if episodic spells + HTN + headache + diaphoresis (pheo screen); sleep study if treatment-resistant + OSA suspected; B12 / folate if older / restricted diet; urine drug screen if substance-induced anxiety suspected; HCG before valproate if bipolar-spectrum considered (CANMAT 2014; APA Panic 2009)
    advance: Targeted workup obtained when triggered
  7. 7DIFFERENTIAL
    Adjustment disorder with anxious features vs GAD vs panic disorder vs social anxiety vs specific phobia vs agoraphobia vs OCD vs PTSD vs MDD with anxious distress vs bipolar mixed features vs hyperthyroidism vs cardiac (ACS / arrhythmia) vs pheochromocytoma vs hypoglycemia vs caffeine / stimulant intoxication vs substance withdrawal (DSM-5-TR 2022; APA Panic 2009)
    advance: Working diagnosis assigned with subtype
  8. 8RISK_STRATIFICATION
    GAD-7 severity (minimal 0-4, mild 5-9, moderate 10-14, severe ≥15; Spitzer 2006); PHQ-9 comorbid-MDD screen; Columbia C-SSRS (Posner 2011); functional impact; psychosocial supports; family history bipolar
    inputs: gad7_score, suicidality_assessment
    advance: Severity tier + comorbidity + safety plan documented
  9. 9TREATMENT
    Mild GAD-7 5-9: CBT first-line + sleep hygiene + caffeine reduction (NICE NG185 2024); Moderate-severe (GAD-7 ≥10): SSRI / SNRI first-line + CBT — combination superior in moderate-severe (CANMAT 2014 Katzman PMID 25081580; APA Panic 2009); failure → switch class → augment buspirone / mirtazapine / pregabalin GAD off-label / gabapentin off-label; treat for ≥12 mo after remission first episode, ≥2-3 yr or indefinite if recurrent (CANMAT 2014; APA Panic 2009; NICE NG185 2024)
    inputs: current_meds
    advance: Stepwise plan documented + therapeutic dose targeted
  10. 10DISPOSITION
    Outpatient: most cases; ED → cardiac r/o + single-dose lorazepam + bridge ≤2 wk for acute panic; partial-hospital / IOP for severe + functional collapse; inpatient psychiatry for active SI with plan / intent / means OR severe benzo-withdrawal OR functional collapse with safety concern OR pregnancy / postpartum with severe disease (APA Panic 2009; VA/DoD 2022)
    advance: Level of care set
  11. 11MONITORING
    GAD-7 at 2, 4, 6, 8, 12 weeks (APA Panic 2009; CANMAT 2014); PHQ-9 at every visit for comorbid MDD tracking; first 4 weeks of any antidepressant high suicide watch (FDA 2004 black-box); side-effect screen (sexual, GI, sleep, weight, hyponatremia in elderly); response = 50% GAD-7 reduction; remission = GAD-7 <5; benzo-taper-progress weekly if applicable
    advance: Response or remission OR step-up
  12. 12FOLLOWUP
    Continue treatment ≥12 mo after remission for first episode (APA Panic 2009; CANMAT 2014 Katzman); ≥2-3 yr or indefinite if recurrent; CBT relapse-prevention reduces relapse 30-50%; lifestyle (caffeine reduction, sleep hygiene, exercise 3-5×/wk × 30 min, alcohol reduction, social engagement)
    advance: Maintenance plan in place